| NPI | 1831765890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NY 32656) |
| Additional Taxonomies | 101YP1600X Counselor, Pastoral (Licence: NY 32656) |
| 324500000X Substance Abuse Rehabilitation Facility (Licence: NY 32656) | |
| Enumeration Date | 2021-06-01 |
| Last Update Date | 2026-05-16 |